58: Rosacea Regimens

Rosacea Regimens

Joseph Bikowski1 and Zoe Diana Draelos2

1 Bikowski Skin Care Center, Sewickley, PA, USA

2 Dermatology Consulting Services, PLLC, High Point, NC, USA


Rosacea is a chronic vascular disorder affecting the facial skin and eyes that typically is characterized by a chronic cycle of remission and flare. Regardless of disease severity (Figure 58.1a–c), this disease has cosmetic consequences for the patient, including flushing, redness, telangiectasia, papules, and/or pustules. Current estimates suggest that 16 million or more people in the USA have rosacea [1, 2]. Because there is no cure for the disease, management consists of the avoidance of disease triggers and the use of both prescription and over‐the‐counter (OTC) products that work in concert to achieve remission, prevent flares, reduce erythema, and camouflage disease manifestations, such as flushing and redness.

Physiology of rosacea

Rosacea is found most frequently in fair‐skinned individuals with Fitzpatrick type I skin which tends to burn rather than tan. UV radiation damages blood vessels and supporting tissue. In fact, cumulative sun exposure is now considered a causative factor in the disease [3, 4]. Rosacea is most often diagnosed in patients between the ages of 30 and 60 years [3, 4], but it also can begin in adolescence – when it is often mistaken for acne vulgaris – or in individuals older than 60 years.

The etiology and pathogenesis of rosacea have not been established, nor are there any known histologic or serologic markers of the disease. However, rosacea is diagnosed by the presence of one or more primary disease features, including flushing (transient erythema), nontransient erythema, telangiectasia, papules, and pustules. Secondary diagnostic features include burning/stinging, plaque formation, dryness, edema, ocular manifestations, peripheral location, and/or phymatous changes [5].

Although these disease features often occur in various combinations, four rosacea subtypes have been classified and agreed upon to assist in the diagnosis and selection of appropriate treatment [5] (Figure 58.2a–d). Subtype 1 is erythematotelangiectatic rosacea (Figure 58.2a), which is characterized by flushing episodes lasting more than 10 minutes and persistent erythema of the central face. Telangiectases are often present. These patients may also complain of central facial edema, stinging and burning, roughness or scaling. A history of flushing alone is common.

Subtype 2 is papulopustular rosacea (Figure 58.2b), which is characterized by persistent erythema, with transient papules and/or pustules on the central face. Subtype 2 resembles acne, but without comedones; however, acne and papulopustular rosacea can occur simultaneously. Papules and pustules also can occur around the mouth, nose, or eyes, and some patients report burning and stinging.

Subtype 3 is phymatous rosacea (Figure 58.2c), which includes thickening skin and nodularities. Rhinophyma, nose involvement, is the most common presentation; however, ears, chin, and forehead may be involved. Patients may also have telangiectasias and/or patulous follicles in the phymatous area.

Schematic illustration of mild (a), moderate (b), and severe (c) rosacea.

Figure 58.1 Mild (a), moderate (b), and severe (c) rosacea.

Schematic illustration of rosacea clinical subtypes: (a) subtype 1; (b) subtype 2; (c) subtype 3; (d) subtype 4.

Figure 58.2 Rosacea clinical subtypes: (a) subtype 1; (b) subtype 2; (c) subtype 3; (d) subtype 4.

Subtype 4 is ocular rosacea (Figure 58.2d), which should be considered if the patient has one or more of the following ocular signs: watery or bloodshot eyes, foreign body sensation, burning or stinging, dryness, itching, light sensitivity, blurred vision, telangiectasia of the conjunctiva and lid margin, or lid and periocular erythema. Blepharitis and conjunctivitis are also found commonly in rosacea patients with ocular manifestations. Ocular rosacea can precede cutaneous signs by years, but it is found most frequently along with cutaneous disease.

Modifications to traditional rosacea classification

An updated classification system was introduced in 2017 based on phenotypes to provide the means to assess and treat rosacea on a more individual basis. A diagnosis of rosacea was considered if one of the following diagnostic cutaneous signs or phenotypes was present: fixed centrofacial erythema in a characteristic pattern that may periodically intensify, phymatous changes. Without a diagnostic phenotype, two or more of these major features or major phenotypes could be considered diagnostic: papules and pustules, flushing, telangiectasias, ocular manifestations. Secondary signs and symptoms may appear with one or more diagnostic or major phenotypes to include: burning or stinging, edema, dry appearance [6].

Rosacea flare

Across the various subtypes and presentations, rosacea typically is characterized by a chronic cycle of remission and flare. Sun avoidance is crucial for every patient to minimize further cutaneous damage, prevent skin cancer, and avoid recurrent flares. There are, however, numerous other possible disease triggers. Table 58.1 is only a partial list of flare factors, but it is sufficient to illustrate how challenging flare avoidance is for patients and why it is nearly impossible for them to avoid triggers completely.

The pathophysiology of rosacea has not yet been fully described, yet new understandings are emerging. It appears that the initial erythema and telangiectasias result from a neurovascular dysregulation and innate immune phenomena to include increased LL37 and serine proteases [7]. In addition, the inflammatory papules are marked by an increase in Th1 and Th17 cells whereas pustules demonstrate increased production of neutrophil‐recruiting chemokines [8]. Disease manifestations and treatment‐related cosmetic sequelae necessitate the use of both OTC and prescription products for long‐term treatment and to treat or camouflage skin redness, flushing, and blemishes.

Table 58.1 Potential rosacea flare factors.

Source: Rosacea Triggers Survey (www.rosacea.org/patients/materials/triggersgraph.php). Reproduced with permission of National Rosacea Society.

Factors Percent affected (%)
Sun exposure 81
Emotional stress 79
Hot weather 75
Wind 57
Heavy exercise 56
Alcohol consumption 52
Hot baths 51
Cold weather 46
Spicy foods 45
Humidity 44
Indoor heat 41
Certain skin‐care products 41
Heated beverages 36
Certain cosmetics 27
Medications 15
Medical conditions 15
Certain fruits 13
Marinated meats 10
Certain vegetables 9
Dairy products 8
Other factors 24

As reported by Members of the National Rosacea Society in its survey of members. National Rosacea Society website, National Rosacea Society. www.rosacea.org/patients/materials/triggersgraph.php. Accessed 29 June 2015.

Rosacea skincare: available OTC products

Rosacea patients often self‐describe their skin as “sensitive”. This is a nonspecific, nonmedical term that can vary in meaning from patient to patient. Therefore, patients should be encouraged to be specific about their skin symptoms. In general, patients with rosacea should be counseled to avoid astringents, soaps, fresheners, toners, facial scrubs, masks, and most OTC skincare “programs.” However, even though the list of verboten agents is long, there are numerous safe and effective cleansers, moisturizers, sunscreens, and cosmetics available for rosacea patients. Disease management is aimed at achieving synergy between prescription and OTC products to ensure maximum efficacy of active drugs, extend remission, and conceal redness and blemishes. People with rosacea tend to have skin that is extremely sensitive to chemical irritants, so it is important that patients try to avoid all sources of irritation. Furthermore, the skin care regimen of a rosacea patient needs to be simple; the more the skin is specifically manipulated the more opportunity there is for unnecessary irritation. Additionally, simplified regimens are expected to encourage adherence.

Cleansing and moisturizing

A proper cleansing and moisturizing routine is an important part of rosacea management. Patients should be counseled that daily cleansing is important to rid the skin of surface dirt, makeup, dead skin, and excess oil, but they should avoid scrubbing the skin and wash with only cool water. The ideal cleanser for rosacea skin is a product that leaves minimal residue, is noncomedogenic and lipid free, and contains nonionic surfactants with a neutral or slightly acidic pH [5]. Table 58.2 lists some recommended cleansers for rosacea patients.

Moisturizing is important in order to maintain the softness and elasticity of the skin, and therapeutic moisturizers devoid of irritants are important adjunctive therapy in rosacea management [9]. A large proportion of rosacea patients have clinically dry skin, and some topical rosacea medications (e.g. topical metronidazole) can cause further drying and irritation. Furthermore, there is increasing evidence that epidermal barrier dysfunction, which is associated with transepidermal water loss and contributes to skin dryness and inflammation, is linked with rosacea. Epidermal barrier dysfunction is associated with elevation of inflammatory serine proteases in various dermatoses, including atopic dermatitis and rosacea [10]. In rosacea specifically, epidermal barrier dysfunction has been identified [11].

Use of moisturizers formulated with a combination of emollients and humectants is recommended to help keep the stratum corneum intact to either repair or prevent skin barrier dysfunction. Furthermore, moisturizing dry skin lessens the itchiness and irritation that rosacea patients often experience as a part of their condition. Some OTC moisturizers are now available that incorporate high ratios of lipids and/or ceramides to support epidermal barrier function. Given the finding of epidermal barrier dysfunction in rosacea, the use of prescription barrier repair agents may be considered for some rosacea patients who do not respond to OTC moisturizers. Table 58.3 lists some OTC moisturizers that can be used as part of a rosacea skin care regimen.

Table 58.2 Recommended over‐the‐counter cleansers for rosacea skincare.

Cleansers Benefits
Avene® Extremely gentle cleanser lotion No rinse, fragrance‐free, paraben‐free, noncomedogenic, nonirritating
Cetaphil® Gentle skin cleanser Lipid‐free, neutral pH, soap‐free, noncomedogenic, fragrance‐free, leaves no residue, nonirritating
CeraVe® Hydrating cleanser Lipid‐free, multi‐vesicular emulsion, soap‐free, noncomedogenic, hydrating, leaves no residue

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Nov 13, 2022 | Posted by in Dermatology | Comments Off on 58: Rosacea Regimens

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